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Skipping Restraints While Monitoring Behaviors

Skipping Restraints While Monitoring Behaviors. Gail Robison, RN, RAC-CT Boyer and Associates, LLC 16655 W. Bluemound Rd. Brookfield, WI grobison@boyerandassociates.com. Goals of Presentation. Examine behavior that leads to restraint use.

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Skipping Restraints While Monitoring Behaviors

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  1. Skipping Restraints While Monitoring Behaviors Gail Robison, RN, RAC-CT Boyer and Associates, LLC 16655 W. Bluemound Rd. Brookfield, WI grobison@boyerandassociates.com

  2. Goals of Presentation • Examine behavior that leads to restraint use. • Assess resident physical, emotional and psychosocial needs to prevent restraint use. • Integrate the facility approach/process through appropriate intervention into your care planning. • Review “Hot Spots of behavior Management systems”.

  3. Resident Risk Areas Leading to Restraint Use • Confusion/Brain Damage from Dementia • Behavior/Cognitive & Mental Health Issues • Physical Complications: intrinsic + extrinsic • Falls/Fall Prevention • Resident/Legal Representative/Doctor Wish • Medication Use

  4. Clinical DiagnosisAffectingPotential Restraint Use

  5. Common Clinical Diagnosis Often Resulting in Restraint Use • Confusion/Mental Illness • Mental Retardation/Developmental Disability • Alzheimer’s Dementia • Vascular Dementia • Lewy Body Dementia • Mild Cognitive Impairment • Major Depression

  6. Common Dementias: Alzheimer’s • Gradual decline • Impaired short term memory • Poor judgment • Personality changes Vascular • Makes definite “steps” in the decline • May include motor symptoms • Usually present with hypertension diagnosis Lewy Body-Approximately 6-10% of all dementias • Fluctuations throughout the day, Difficult to Diagnose • Hallucinations that include non-threatening person around them • Parkinson’s like symptoms • Erratic Behaviors

  7. MCI: Mild Cognitive Impairment • Function that does not significantly interfere in functional abilities • Memory complaint • Abnormal memory for age • Normal General Cognitive Function • Normal Activities Daily Living • 2 types: amnestic (30%) “early Alzheimer” and non-amnestic (70%)

  8. Signs of Major Depression • Persistently depressed mood • Diminished ability to take pleasure in activities • Feelings of worthlessness or excessive guilt • Difficulty thinking and concentrating: indecisive-ness • Thoughts of death, suicidal indentation, suicide attempt • Excessive tiredness • Significant altered appetite and weight • Too much or too little sleep • Psychomotor agitation or retardation • Criteria for diagnosis does not include: result of drug usage, medical condition

  9. Physical Complications: • Intrinsic + • Extrinsic Causes of Problematic Behaviors • Often results in Restraint

  10. Potential Intrinsic Causes of Problematic Resident Behavior • Chronic illness • Progressive dementia • Chronic pain • Progressive diseases (cancer, arthritis, heart disease, respiratory diseases) • Side effects of medications/medication interactions from poly pharmacy • Impaired hearing, vision, communication, sensation, taste • Fluid or nutritional deficits • Changes in continence of bladder and/or bowel • Perceived fear, anxiety, stress related to previous life experiences, impaired or altered perception, mental illness or changes related to disease • In determining cause also review for: infection, bowel issue, presence of unrelieved/un-verbalized pain, or sleep issues.

  11. Potential Extrinsic Causes of Problematic Resident Behavior: • New or unfamiliar environment • Unfamiliar staff/situations • Lack of stimulation/familiar experiences/activities • Over-stimulating environment/activities • Caregiver approach • Unfamiliar schedule/routine • Long-standing personal dislike/fear of an activity or task • Anger/grief related to time of day, year, season, type of weather • Grief over loss of loved one, possession, home

  12. Fall’s the #1 Risk For Restraint Use or Prevention

  13. Fall Risk Internal Risk Factors: * medical issues: cardiac, hip fx, hemiplegia, parkinson’s * behavior issues: dementia, delirium, cognitive decline, depression * physical issues: gait disturbance, joint pain, seizure disorder, inactivity with loss of strength, endurance and flexibility * care related issues: incontinence, uti, visual or hearing deficits * lifestyle issues: inadequate nutrition: vitamin D+ Calc * nutrition issues: protein and calorie, adequate fluids, alcohol intake

  14. Fall Risk External Risk Factors: • Medications: narcotic, coumadin, psychotropics: anti-anxiety, anti-psychotic, hypnotic/sedative, anti-depressant, antihypertensive, diuretic, hypoglycemic, laxatives, analgesic, anti-parkinson, steroids, anticonvulsant, relaxant • Vital signs: orthostatic vitals: supine, sitting and standing Appliances and Devices: • Restraints/enablers in use • Devices in use: wheelchair, walker, cane • Call light in place • Alarm in use Environment/situational hazards • Examine closely the resident environment: room, community

  15. Nursing Process/System Process Per Guidelines, results Behavior Trending: Avoid Restraints Clinical Condition history, risk factors and extensive assessments Behavior tracking/targeted behavior tracking Medication + Behaviors Determine the Behavioral Interventions Behavior Interventions Behavior Management: Scheduling correctly Develop the POC

  16. We’re All In This Together

  17. Clinical Documentation Collaborative Team Who are WE? • Nursing • Therapists: PT, OT and SLP • Physician (s) • Social Services • Dietician • Activity Therapy • MDS Coding/Scoring

  18. Overview of the RAI Process • Assessment (MDS/other) • Decision-Making (RAPs/other) • Care Plan Development • Care Plan Implementation • Evaluation

  19. Individual Discipline Assessment • Must be done prior to or on the ARD • Should be supported by evidence of testing per MDS guidelines and supportive documentation • Behavioral/cognitive/decision-making/memory • Communication • Nationally approved supportive testing appropriate to diagnosis and/or medications in use to validate the need for continued usage

  20. Psychosocial Testing • Cognitive Performance Scale • Cornell • Clock Test • Geriatric Depression Scale • Hamilton • MMSE

  21. Assessment • Review the resident’s most current MDS for identification of causative factors. Review the Mood/Behavior RAP to further identify problem areas. • Obtain a thorough history of the resident which may provide insight into possible causes of the behavior • Also review prior hospital, medical information, lab reports, physician progress notes, interview family and resident, previously administered medications and past treatments. • The Behavioral committee will review and discuss the data collected

  22. Critical Factors: Wisconsin • Behavior Add-on • Data elements • E1 d,h,I,n: (d) anger, (h) repetitive health complaints, (l) sad (n) repetitive physical movements • E4 a,b,c,d,e: wandering, verbal abuse, physical abuse, social inappropriate and resists cares • E2: mood persistence • P2a,b,c,d:interventions programs for mood/behav/cog loss, special behavior, mental health psychiatric specialists, group therapy, environmental changes etc. • G1e-locomotion on unit • P1am:alcohol/drug treatment • P1ar:community skills: trainings • J5a: condition/disease make resident’s cognitive, adl, mood/behavior, pattern unstable with fluctuating, precarious or deterioration.

  23. Integrate the facility approach/process through appropriate intervention into your care planning

  24. Behavior Interventions-70 items • Discuss old memories, reminisce • Know + use the resident talking points • Verify clothing fits comfortably • Assess for acute illness: fever, labs, urinary testing • Identify yourself and speak slow, calm and let resident know what you’re going to do to help • Break tasks into small tasks • Give choices slowly, don’t overwhelm • Offer a handshake, hold hand, touch • Check need to toilet • Check for recent bowel movement/constipation • Check for new medication (s) • Offer reassurance • Therapy screening/evaluation • Promote a continuous program: eating, toileting, activity, rest, re-run

  25. Respond to behavior (s), emotion (s) • Give object to hold • Give activity box of interest • Remove from environmental noise, stimulation • Read to resident • Talk softly and with interest • Give a repetitive task that they may enjoy: sorting, folding etc. • Check room environment: mirror, pictures, colors, etc. • Don’t argue, or react • Monitor for hallucination/delusions and approach calmly • Don’t do re-orientation or reality orientation • Pain-related conditions-assess pain and/or pain management • Verify for medication error • Check foot wear • Monitor for sensory issues: vision, hearing loss, • Evaluate sleep hygiene, insomnia • Modify daily life situations • Limit choices • Aromatherapy

  26. Modify positioning, reposition • Don’t argue and or try to reason with • Remove items that indicate leaving • Offer food, may be hungry • Offer fluids, may be fluids • Provide rest and develop a routine rest period • Lower stress • Provide relaxation strategies: hand touching, massage, etc • Offer calming music consider primary language evaluate cultural influence • Try teaching based on ability to understand • Set agreed goals • Accommodate individual needs/tolerance/evaluate • Identify deficits/abilities, feelings • Separate residents in conflict/hostile • Regulate patterns and interactions • Don’t close in or surround resident • Reduce noise • Dim bright lights

  27. Create environmental cues • Allow the most effective staff members to take the lead • Improve comfort level • Correct reversible medical causes • Verify medical problems/treatments • Improve communication • Consult pharmacist/physician for safe dosage or reduction • Learn the resident warning signs • Remember and record the behaviors that work • Keep interactions simple • Meet basic needs; thirst, hunger, temperature, comfortable home • Distract with activity • Increase physical movement • Use night lights • Limit evening fluids • Discourage long daytime sleeping • Limit caffeine intake • Relax before bed • Try a backrub or hug

  28. Implementation of Intervention/Care Plan Development • Place the resident on 24 Hour Report • The interventions shown to decrease the resident’s: distress/targeted behavior (s) improving the resident’s quality of life and “skip” restraints will be entered on the care plan. • Determine resident specific, measurable goals and time frames. • Identify the resident’s condition/targeted behavior (s) and specific interventions to be used by staff when the behavior is present • Educate the staff to which interventions are most effective. • The Behavior Management Team designee will review and analyze the information documented. • Continue with specific interventions known to be effective in Re-evaluate the effectiveness of the plan with any change in the resident’s response of condition, and routinely with completion of the MDS.

  29. “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” Arnold Glasgow

  30. RISK Committee Analysis • Restraint Use is Not the STANDARD of Practice • Any Condition change that raised the question of Restraint Use should be closely scrutinized. • Administrative Approval- Careful selection • Take discussion to RISK Committee for analysis of an alternate plan • Consider Behavior Management Committee as RISK Committee

  31. Behavior Management Policy: Your Facility’s Behavior Management Program will consist of: • Maintaining an effective Interdisciplinary Behavior Management Committee • Ensuring a thorough and comprehensive assessment of the resident’s needs, behaviors, and prior medication and medical history • Monitoring the resident’s behavior (s) to establish patterns, determine intensity and behavior frequency, and identifying the specific (“targeted”) behavior (s) that are distressing to the resident which are decreasing the resident’s quality of life • Thoroughly assessing the need for psychoactive medications into the resident’s medication regime • Along with the resident and their surrogate, weighing the risks and benefits of adding or eliminating psychoactive medications. • Planning and implementing appropriate interventions into the resident’s plan of care • Evaluating the effectiveness of Pharmacological and non-pharmacological interventions • Monitoring for any adverse side effects of medications, which includes completion of Abnormal Involuntary Movement Scale (AIMS) as per recognized standards of practice

  32. Behavior Management Programs Prevent Restraint Use and Add Quality of Life • Philosophy:Your Facility believes that all resident behavior has meaning. It is the pledge of Your Facility to work to identify the cause and meaning of behaviors that are distressing, and impact negatively on the resident’s quality of life. Your Facility will work diligently to minimize use of psychoactive medications and physical restraints for the resident population.

  33. Purpose: • To implement the most desirable and effective interventions that meet both the known and unknown needs of the resident, to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or impacting on the residents’ quality of life. • To increase desired behaviors, promote resident safety and security, and to enhance the resident’s ability to interact positively with his/her environment.

  34. The Behavior Management Team • The Behavior Management Committee will consist of at least the following: • Director of Nursing/designee • Social Services • Consulting Pharmacist • Nurse Manager (s) • Activity Department Representative • Dietary Representative (As determined by Committee) • **The committee chair is facility specific and often will be the Director of Social Services

  35. Behavior Management Team Care Process: Medications are an integral part of resident care. The Behavior Management Team will effectively manage the Diagnosis, behavior and/or psychoactive medication process for the residents by: • Recognizing and Identifying problems which affect the resident’s behavior • Assess and define causative factors of the identified behaviors and any related diagnosis • Manage, treat, develop, and implement effective approaches • Monitor on a regular basis, and with change the approaches implemented for effectiveness • Re-evaluate, assess, and modify approaches as needed

  36. Role of the Behavior Management Team: Medication Management: • Verify that medications that have a “black box” warning, or have the potential to cause significant adverse consequences should be identified on the residents care plan and the risks and benefits are clearly explained to the resident/surrogate. • The Behavior Management Committee will ensure the prescriber’s order for the Dose of medication is based on the following: >Resident’s diagnosis >Resident signs and symptoms >Resident’s current condition, age, >Resident’s labs, and other related tests >Co-existing medication regime • Duplicate therapy does not occur unless current standards of clinical practice and documented clinical rationale confirm the benefit

  37. ???????????????????Questions+Answers

  38. Thank You! Boyer & Associates, LLC

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